The national obesity rate for the USA continues to rise, crossing the 40 per cent mark for adult obesity in 2020. With an increase in obesity comes an increase in surgeries and methods to combat it. Even if you are not at risk, you may want to know if bariatric surgery is an option available for a loved one via their insurance provider. And if not, what other options do you have?
Table of Contents
- 1 Do Most Insurance Companies Cover Bariatric Surgery?
- 2 What Insurance Pays For Bariatric Surgery
- 3 Does The Affordable Care Act Cover Bariatric Surgery?
- 4 How To Pay For Bariatric Surgery Without Insurance
- 5 Revision Bariatric Surgery Insurance Coverage
Do Most Insurance Companies Cover Bariatric Surgery?
Bariatric surgery can cost anywhere between $10,000 to $20,000, depending on the patient, the seriousness of the issue, the locality and the type of surgery you are going for. Given the extent of the obesity dilemma, many insurance companies give their clients the option of providing some coverage for the surgery. Some companies require a copay of a few thousand dollars for the surgery. A copay or copayment is a fixed amount that your insurer specifies you have to pay for a service that is covered under your plan before you get that service.
Before the insurance company agrees to cover your costs, you will be required to qualify for the insurance. This means working with your doctor and insurer to get the necessary paperwork in-line for the company to process your application. Though it depends from company to company, some of the requirements you may have to meet for getting insurance for the surgery includes:
- Having a Body Mass Index (BMI) of 40 or over 40 for two or more years.
- Having a BMI of 35 or more and weight-related health problems like diabetes, sleep apnea, blood pressure etc.
- Having tried to lose weight in the past using a restricted diet and exercise but without success.
- Documented proof of having participated in physician-supervised weight loss efforts.
- Be 18 years or older.
As a patient, do not get discouraged if your application gets rejected. 25 per cent of people who apply for gastric surgery insurance get rejected. You have the right to appeal an application if it is turned down.
What Insurance Pays For Bariatric Surgery
Whether you are publicly or privately insured or have insurance through your company or individual insurance, it depends on your plan and the need for surgery that determines if your insurance will pay for it or not. Check with your insurance company to see if bariatric surgery is an option through your plan.
Medicare and Medicaid also provide insurance coverage for certain gastric surgeries, like laparoscopic banding surgery and gastric bypass surgery. However, approval by Medicaid may take up to 5 months as they review your application, whereas your insurance company may take only up to a month for the same process. Some other insurance companies that pay for bariatric surgery include Aetna, CIGNA, Kaiser Permanente, Presbyterian Healthcare Services, Priority Health etc. Check Bariatric Surgery Source’s Insurance That Covers Bariatric surgery for more companies.
Does The Affordable Care Act Cover Bariatric Surgery?
The Affordable Care Act (ACA) or Obamacare, passed in 2010, was an effort to make healthcare accessible to all. However, the ACA covers bariatric surgery in 23 out of 50 states only. The rest of the 27 states are those with the highest rates of obesity. Public representatives in these states are petitioning for the ACA to cover bariatric surgery for the rest of the 27 states as well. Check with your states healthcare laws to see whether ACA covers bariatric surgery in your state or not.
How To Pay For Bariatric Surgery Without Insurance
If your insurance claim for bariatric surgery has been denied, don’t panic. There are certain alternatives to pay for bariatric surgery without insurance:
- Go for an appeal.
- Self-payment options.
- Payment plans, loans and financing.
- Sponsors or charities.
Let’s look at some of these options in more detail.
How To Go For An Insurance Appeal To Pay For Bariatric Surgery
To go for an appeal, start with an oral complaint to your insurance provider. You may need to get additional documents to make your appeal successful. Most insurance providers only accept appeals within a limited number of days after the denial. This is usually up to 60 days.
If you have decided to appeal the decision of the insurance company, start by checking if your plan provides bariatric surgery coverage or not. If you have your company’s health insurance, contacting the HR department for your insurance details. Next, contact your surgeon. Many clinics now have expert denial staff that helps with the appeals process. Get records of your family’s medical history that will make your case stronger. You may need additional documents from your surgeon about your medical health as well.
With your appeal application, attach a letter explaining why you must get the surgery. Mention the facts – emotional rants will not help your case at all. You may want to include a letter from your surgeon as well, that corroborates your need for surgery. Other documents will include a copy of the denial for insurance and additional medical documents. Request for an explanation of the denial. If you are still denied, check if you can appeal again or contact your state’s Department of Insurance. You may be patched up with people in the department who work specifically on denials.
Self Payment Options For Bariatric Surgery
If your appeal is continuously denied, you may consider the options of paying for the surgery by yourself. You can ask friends and family to help you with the cost and take small loans from them. You may also consider fundraising for your cause. You can use a website to fundraise or hold a games event or bake sale to raise the funds. You may also check to see if you are eligible to receive tax refunds
Payment Plans, Loans And Financing For Bariatric Surgery
Many countries have payment plans to help pay for certain life events. You can go for a bank loan, a medical loan or surgeon financing.
If you’re going for a bank loan you may need to submit your credits history and proof of being able to pay back the loan. You may go for a secured loan with lower interest rates or an unsecured loan with higher interest rates. You should only consider getting a secured loan when you are absolutely sure you will be able to pay it back, without jeopardizing your collateral.
If your bank refuses to give you a loan due to any reason, you may go for a credit union loan (needs lesser credit scores and offers lower interest), or contact a marketplace or online lender for a loan.
You may also look to get a medical loan for your surgery. These loans are unsecured, meaning you don’t need to provide collateral and they get accepted much faster, sometimes within a day so you don’t suffer long delays in your surgery. You surgeon may be able to recommend you to a third-party medical loan provider for your surgery as well.
Ultimately, you can talk to your surgeon and agree upon surgeon financing as a way to pay for your surgery. If you are able to make a healthy down payment, your surgeon may charge you with a very small interest rate. Alternatively, your interest may be much higher if your down payment is small. They may also offer you a financing plan through a partnered finance company. Whatever the plan may be, make sure that it covers all pre and post-op costs for your surgery.
Grants For Bariatric Surgery
The Weight Loss Surgery Foundation Of America is one of several not-for-profit organizations that provide grants for gastric surgery if you are obese, have qualified for the surgery but do not have the financial power to pay for it. Keep in mind though that grants are much difficult to obtain as compared to some other options.
Sponsors Or Charities For Bariatric Surgery
Many people who suffered from obesity in the past now have charities to help other people. They may also provide sponsorship for serious cases. Certain hospitals also provide charity care and may consider to help you if you fall below the poverty line.
Revision Bariatric Surgery Insurance Coverage
Insurance companies do provide revision bariatric surgery insurance coverage if you qualify for it. Revision bariatric surgery is undertaken if the original surgery had complications or has less than optimal results. An insurance company will only cover for the revision bariatric surgery if it is proven that the original surgery failed because of actual complications or if the patient failed to comply with post-op procedures. If it is the latter, the insurance company will generally deny claims for coverage.
When applying for insurance claims for revision bariatric surgery, make sure you and your surgeon are agreed upon why the surgery failed in the first place. Provide all necessary medical proof, like CT scans, MRI and endoscopy results that show the need for the revision. You may also argue that though your weight has fallen and your BMI is down, you are at a greater risk of increased weight gain if you don’t have revision surgery.
To conclude, individual health insurances do cover bariatric surgery, provided your case is strong. Bariatric surgery is a necessary medical procedure that has helped many people fight health problems and co-morbidities.